In the rush to get results fast and take shortcuts, or to “get to the interesting stuff” young athletes get broken. Improving the structural integrity of the athlete is essential before moving onto other areas of fitness.
Watching Alien Covenant this week prompted me to update this blog as they used the phrase also.
I used to say that Structural Integrity is composed of 4 key components:
Balance: Static and dynamic, upper/ lower body, single limbs.
Stability: Joints are strong and can support body weight when moving and static.
Mobility: How you control limbs over a range of movement.
But, when presenting at the DAASM symposium in April, I was challenged on the use of “stability” By Dr. Homayun Gharavi MD, PhD, PhD. He suggested that the word “control” is better than stability. Stability has been overused and is vague, the body is designed to move, unlike a table, and so control is more accurate.
This means the new schematic would be this:
The Foundation of Athletic Development
Most of the athletes I initially encounter have glaring deficiencies in their structure or posture that limits their ability to progress. Loading athletes like this either through volume, intensity or weight, will lead to breakdowns. Saying someone needs to get fitter and then giving them a running programme, without seeing them run, is poor coaching.
Instead, after their initial musculo skeletal and movement screening, we start to work on their structural integrity. This is the foundation of Athletic Development and then allows the athlete to work on their athletic ability involving spatial awareness, rhythm, movement abilities and timing. This then allows greater ease of skill acquisition. In this video you see an example of work with young gymnnasts.
Bill Knowles doesn’t have any magic answers or quick fix exercises. His approach to injury rehabilitation based on good coaching and insisting on excellence in every exercise means injured athletes getting back to competition readiness sooner.
Knowles delivered a quite extensive review of his methods and some research on “Return to competition strategies for the load compromised athlete”. This included video clips of his athletes working and also his ideas on creating the right environment and team for athletes to excel within.
He started out having to work with big groups of people and not much kit, so he had to innovate and adapt right from the beginning.
Planned Performance Reconditioning (PPR) not injury rehabilitation
Knowles started with talking about why he doesn’t use terms like “prehab” or “rehab”. These imply start and end points and a medical based model. The athlete would then walk back on to the pitch, start competition and get reinjured.
Instead, the PPR should be an opportunity to get the athlete better and to ensure that they are stretched, challenged and engaged throughout the process. “Ultimately injury is an opportunity to become a better soccer playing athlete and potentially a better soccer player”.
In high performance sports you should STRIVE for a better soccer player.
In order to evaluate and plan what you are doing you need to combine Evidence Based Medicine (Science) with Experience Based Evidence (Art).
The coaching of the rehab process was emphasised time and again, the athlete and the exercise must be coached well. “Exercise is something you do, movement is something you feel” get the athlete out of the injury and remember who they are”.
A Joint Compromised Athlete is a Load Compromised Athlete
The joint is not to be trained in isolation, it is part of the whole body and the loading has been compromised too.
Once you are a LCA you are always an LCA. That is why you need an “Athlete Sustainability Programme”. This is something that is included throughout the year to prevent lapses.
This is a Performance based model, compared to a Physio or Medical based model: they are not experts in planning performance training.
This was a theme that came up several times over the conference (And Rob Newton mentioned this at the RFU conferencetoo about Australian sport) where teams are now letting physios lead training sessions with “Pilates” or “core” and wondering why they are not performing on the pitch!
“It’s a brain injury dude”
Knowles explained something called “Arthrogenic Muscle Inhibition” (AMI) which is the change of the sensory receptors due to injury. This results in an inability to completely contract a muscle.
This is a bilateral situation: Quadricep activation deficits of 7-26% in the unaffected limb have been measured. After an ACL injury the athlete is more likely to tear the opposite knee, and more likely to get reinjured than the non injured athlete.
The AMI is severe in the short term, plateaus at about 6 months, and slowly declines over the next 18-33 months! So, training the rest of the body is important to prevent that getting weaker too. This must be continued for nearly 3 years!
The brain has to be worked and rehabbed too: so lots of new challenges, games and activities must be included to ensure the athlete is ready to play and compete.
“The knee bone is connected to the head bone”.
The Central Nervous System has been affected, so this must be trained too: “It is not a race to get them back, it is a process to get them better” Gambetta.
Envelope of healing
The upper limit of the envelope is for the elite athlete, but too much work leads to inflammation. Too little work is safer, but it is not causing enough adaptability.
There are no time frames for the rehab procedures, instead criteria based progressions are needed. Function leads to the next stage. For example, biologically running might be right after 8 weeks, but mechanically the loading ability isn’t ready.
The LTAD process gets interrupted by an injury, so other areas need to be worked on during the recovery. Contact sports players need to be “toughened up” to prepare for training, others can develop volume, load or skill ability. It can be a time to “increase the player’s bandwidth” of exercise competency.
There are so many things that can be done to “stop the bleeding of skills and mindset” when injured. Knowles gave great examples of working with golfers and soccer players on using limited skills, or slower actions with severely injured players very early on in the rehab process.
It was great to see how a World Class expert in rehab works, and how he is passionate about coaching athletes. The videos we watched and practical demonstrations we saw and did later really opened my eyes. (Physiotherapist Sarah and I discussed this when doing therebounder exercises).
The “Progression, Variety and Precision” that Ed Thomas talked about were very apparent in Knowles’s work.
One of the good things about GAIN is the interaction between different professions. Everyone was learning from each other and recognising the transfer across areas.
Come to our clinic
If you want your sports injury rehabilitated, then you can come to our clinic based in Willand, Devon. Physiotherapist Sarah Marshall and myself have helped many athletes return to competition from injury.
The screening of an athlete is used to identify the current musculo-skeletal condition of that individual. If carried out initially during the pre-season period, it can provide a set of baseline values for the athlete’s data base or personal physical profile.
Repeat screenings through-out the season can then identify any physical changes. This is particularly important with a growing and developing skeletal system.
At Excelsior, we use a baseline screening of 5 different exercises that assess the individual’s ability to move in 3 dimensions in a co-ordinated fashion. We are looking to find out what a person CAN do as opposed to what they CAN’T do.
We look at Posture, Balance, Stability and Mobility and this helps us guage the movement efficiency of the athlete.
Why do we screen ?
A functional screening assessment will identify an individual athlete’s musculo-skeletal strengths and weaknesses. From these results, an accurate rehabilitation / conditioning programme can be implemented.
Historically, screening would involve observation of static posture and a normal gait pattern. Non-functional assessment of joint movement, muscle strength and flexibility would be carried out. This might include various single joint assessments in sitting or lying positions.
This is good for identifying individual areas of weakness.
However, sports people rarely use single joint movements in these positions; instead the body works as one unit. By looking at the overall movement we can see the context in which any problems occur.
Sport Specific Screening?
Whilst it is important to understand the needs and demands of the sport, we do a screening that is Athlete specific, not sport specific.
An assumption is often made when designing training programmes that the athlete is able to perform basic movements and then start loading them.
Unfortunately experience has shown that this is the exception rather than the norm.
Anecdotally less than 10% of the sports people we screen have been able to perform the basic movements well.
Sports people are a product of their environments and postureis affected by daily living (driving, sitting, lying) or by their sport (racquet sports and throwers being one sided for example).
Prolonged exposure to poor posture can lead to problems.
(The lady pictured has a slumped position at her laptop. This then transfers to standing and holding the racquet.)
By improving an individual’s movement patterns first, injury risk will be reduced.
Then we can address the needs of the sport and performance can be enhanced.
Repeat screenings can be especially useful post-injury to help determine an athlete’s return to competition.
If you would like more information on screening for you or your athletes, I am happy to answer your queries: we are based in Willand, near Cullompton & Tiverton.
You contact me here Physiotherapist Sarah Marshall
‘Good posture is the state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity irrespective of the attitude in which these structures are working or resting.’ (1)
Why is good posture for athletes so important?
Having good posture means the body is aligned correctly and can work more efficiently.
Having bad posture means that the body is not balanced, therefore your muscles and joints have to work a lot harder because you are trying to align AND move accordingly for your sport.
Why is bad posture so common and how can it affect me?
Lifestyle has changed everybody’s posture dramatically. Adults and children will spend the majority of their day in a seated position i.e. at work hunched over a desk or computer, at school slouched in the chair or again over a desk and driving or being driven.
You will see a lot of bad standing positions too. It’s quite common to see young people shifting their weight onto one leg when standing too. Our bodies are active when we stand, not resting, the muscles should be working to keep our bodies upright. When we slouch we are ‘hanging’ off the joints.
As stated above, bad posture means our bodies have to work harder than usual in any activities we do. It can also cause chronic aches and pains and can lead to injuries in sports because the body isn’t efficient.
Two types of ‘bad’ postures
Exaggerated curve in the Lumbar region of the spine (bottom sticks out, stomach sticks out)
Caused by tight hip flexors – too much sitting – weak abdominals – relaxing these muscles when sitting rather them using them to support the spine.
Stretch hip flexors to increase length. Strengthen stomach muscles (sit up tall as well). (2)
Exaggerated curve in the Thoracic region of the spine (hunched back, head leans forwards).
Caused by sitting like this at desks/ computer, driving/texting. Results in weak upper back muscles due to being overly stretched and tight chest muscles due to no stretch given in this posture.
Stretch chest muscles. Strengthen upper back muscles. (3)
Can some sports cause bad posture unintentionally?
Typical gymnastic posture
Take a look at gymnastics for example. Their common posture is more towards Lordosis. This posture is ‘practiced’ a lot i.e. after landings and during dance on the floor.
Also, due to their flexibility, a lot of gymnasts will stand badly i.e. bowed or locked out legs and flexible lumbar region of the spine which emphasises the Lordosis posture.
Gymnasts will have trained early (early specialisation) causing their bodies to only know that way of moving, rather than trying out a lot of different sports and allowing their bodies to balance out.
Golf also repeats the kyphosis posture too, standing with a ‘hunched back’ before swinging the club, although keeping a straight back before is ideal.
Also, golf is very one sided, so there will be an in-balance due to this e.g. if you stand with your left foot at the front, your right side will be stretched after hitting the ball where as your left side won’t.
So as you can see, lifestyle really affects our posture.
Correcting it early on in life and just being aware of it as often as possible will help athletes bodies become a lot more efficient.
This will transfer into their training and games/matches.
Sit up and stretch if you are sat for long periods of time, try standing on both legs rather than shifting your weight onto one leg, and stand tall as well. All these will help and eventually become automatic for you.
This video shows you how to work on the 3 uncommon postures:
Nick Allen is the clinical director of the Jerwood Centre, and looks after the dancers of the Birmingham Royal Ballet. His lecture was well structured, informative and entertaining. He gave an overview of the different aspects of dance training, the problems he encounters and some of the solutions.
Dancers are athletes
The dancers do 150 shows a year, about 8 shows a week when it is running. Their day might start with a 90 minute class, rehearsal in the afternoon, perform in the evening. They sometimes rehearse and perform different shows on the same day.
They train on a flat studio surface, with good force reduction properties. The stages are irregular in nature, with variations in force reduction properties, and it has a 4% rake (tilt) from back to front, to allow the audience to see all the dancers.
So they train and perform on two very different surfaces. Allen then went through some stats and ideas on how they have tried to bridge this gap through improving the home stage, but travelling is still problematic.
The impact is not helped by the fact that the dancers wear shoes that they proceed to batter to make them look better, and thereby negate any hope of having support in their footwear.
Wearing costumes also adds stress to the body, with some dancers losing 5kg of weight in each show, despite taking on 3 litres of fluid. Allen has been working with costume designers to try and make the costumes more breathable.
All this led into the type of injuries the dancers have: medial tibial stress syndrome (shin splints) is very common and the males have more thoracic back injuries (due to lifting females) and the females have more facet joint injuries in the lumbar spine. The ACL rupture protocol is for a 9 month rehab, which leads to stronger knees on return. Allen used to work in premiership rugby, where 6 month protocols were used, and this led to further injuries.
Allen then went through the training philosophy, which looked at building the foundations first. This involved 4 layers of “bricks”with the bottom being motor learning; the next layer being flexibility, strength and skill, the next layer being endurance and the top layer being performance. (I really liked this graphic and it makes a lot of sense to use something similar with all athletes).
Allen then compared the likelihood of injury between athletes and dancers at 2 different ends of a continuum. An athlete will have levels of strength and fitness, with less skill, so if they get a move wrong they can cope with it.
But get it wrong too often and then they will get injured. A dancer on the other hand will be very efficient at each move, but weak, so if they land or jump or lift out of place- they get injured.
Allen then described how he looks at the function of the movement, understanding the asymmetries within the dance. He looks at function over pathology, and efficiency of movement. He ended the lecture with an aside about bone health – 80% of the dancers have vitamin D deficiencies, some smoke, some are amenorrhoeic – which leads to more stress fractures.
A very informative lecture, which showed a sound methodology of analysis and training, together with some imagination and innovation. I will be following up on a lot of this information over the next couple of months.